decisionhealth Newsletters, Answer Books - 2009 Issue 1 (January)
Appendix D - 1997 EM Guidelines / I_Introduction
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Article Overview
This article introduces the role of medical record documentation in evaluation and management guidance. It explains the general purposes of documentation, how it supports patient care and administrative processes, and why payers may request supporting information. The content is intended for coders, billing staff, clinicians, and compliance professionals who need a broad understanding of documentation expectations.
Why This Topic Matters
Understanding documentation fundamentals is important for accurate claim support, continuity of care, and administrative review. This introduction frames the broader guidance that follows in the 1997 E/M guidelines appendix.
Article Sections
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What Is Documentation and Why Is It Important?
Defines medical record documentation in broad terms and explains its role in patient care, communication, review, and recordkeeping.
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What Do Payers Want and Why?
Describes the general reasons payers may ask for documentation and the types of information they may seek to validate.
What You Will Learn
- The general purpose of medical record documentation
- How documentation supports patient care and continuity
- Why documentation matters for claims review and quality assessment
- Why payers may request supporting records
- The role of documentation in compliance and recordkeeping
Who Should Read This
- Medical coders
- Billing staff
- Physicians and other clinicians
- Compliance professionals
- Revenue cycle staff
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